Covid-19 Gambles

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Any readers of ‘War and Peace’ out there? :)

Although only 'scratching the surface' (of a very complex issue), this is going to end up very long [split into two posts, because of a 10,000 character limit] and. probably for most of you, 'boring' - so please only read it if you are really interested.

It is also probably a bit muddled and repetitive, for which I apologise, but I have written it in some haste. I also apologise for posting it in this forum (f it 'survives' here), for which it is about as 'off-topic' as one can imagine but, as I said in the other thread, this is one place where I feel that I am 'amongst friends'!

If I get a chance (hopefully quite soon), I will post some graphs to illustrate some of the points I make below, and also to perhaps stimulate some thought/discussion about related issues.

In another thread ...

I suggest you need to read a bit wider.
It's not 'more reading' I need - I think I've done enough reading, and playing with data, in relation to this issue to last me a lifetime :) I have been (and am) working closely with some groups of academics in attempts to model/forecast the future of the Covid in the UK in various scenarios. It is those activities which cause me, and many of my my colleagues, to have significant concerns.

Managing the situation in the sort of manner that is proposed comes down to some massive gambles. Medicine, Science and Mathematics can give some guidance as to what might happen in various scenarios, but it is obviously government which than has the unenviable task of deciding which gambles are 'gambles worth taking', and which would probably be 'a gamble too far', by attempting to balance the countless considerations.

The decisions are mainly 'gambles' because 'the science' can only talk with certainty about what has already happened - all attempts to predict/forecast the future inevitably come with 'uncertainty'.
There has been scientific advice that delaying things would actually cause more health problems because it would push the resulting wave back into the autumn and winter when it will collide with the seasonal flu season - which is seasonal simply because this sort of thing thrives best in certain conditions. By doing it now, while conditions are not good for the virus, it will flatten the peak and more of the peak will be over before we get into flu season.
That's one of the 'massive gambles'. That whole approach is based on the assumption/hope that the current 'wave' (which will inevitably become worse if the upcoming 'freedom' happens as currently envisaged) will be substantially 'over' by the time the 'flu season comes. If that doesn't happen as 'hoped', and the prevalence of infection remains higher at the start of the flu season than it would have been without July 19th 'Freedom', then the consequences (to the NHS etc.) of the 'flu will simply add onto persisting elevated Covid-related calls on the resources.

As discussed below, we are in a situation of very high and rapidly increasing virus prevalence and, although we 'expect'/hope (and maybe pray!) that increasing impact of the ongoing vaccination campaign will 'reverse' that trend fairly soon/quickly, we really have little idea of when, how quickly and to what extent that would happen.

Virtually any other country (which didn't have our level of vaccination and/or our degree of extreme 'faith' in it as a means to 'salvation') in this situation would probably be markedly tightening, not nearly abolishing, their control measures). We know little with any certainty about what would happen even without any 'relaxations' - so we know even less about what might happen if we add the consequences of 'Freedom Day' onto that already uncertain future.

One thing (which really illustrates one of our main concerns) that my colleagues and myself somewhat struggle to understand is why both the government and their advisors seem to be suggesting that, following the planned relaxations in just over a week, the number of new cases per day "might rise to as high as 100,000 per day later in the summer", since that seems to potentially be a serious understatement of what could/might happen ...

... there were about 32,500 new cases in the UK on Thursday 8th ('today', as I start writing this). The figure has been rising rapidly (exponentially), and the most recent SAGE estimate of rate of rise (in England) is 2%-5% per day, corresponding to doubling about every 14 to 35 days - hence a 'best estimate' (middle of quoted range of uncertainty) of about 3.5% increase per day (which corresponds to doubling in about 20 days).

If that pattern of exponential rise continues at the 'best estimate' rate between now and then, by 19th July there would be around 47,000 new cases per day. Even if there were no relaxations on that day, but the rise continued at that rate, by the end of the month (12 days after 'Freedom Day') there would be around 72,000 new cases per day, and about 100,000 per day by about 10th August.

If the rate of rise continued at the current 'upper bound' of the estimate (5% per day), there would be about 56,000 cases per day by 19th July and, even if no 'relaxations' happened on that day, about 100,000 by the end of July and about 160,000 per day by about August 10th.

As discussed below, although currently pretty low (in comparison with the first and second 'waves') hospital admissions and ICU bed occupancy are also rising at a rapid rate. Hospital admissions (and similarly for ICU occupancy) is currently rising at around 6% per day (doubling in roughly 12 days).

The 'gamble' obviously assumes that things will not be anything like as bad as those figures and that, rather, the increasing impact of continuing deployment of vaccination (really the only credible thing, other than increased restrictions, that can help the situation) will [one is gambling 'very soon'] slow, and eventually reverse, the current rise in cases.

However, with the best will in the world, it is very improbable that the effects of increased vaccination are going to have a marked effect within the next week or three, particularly given that it will be a couple of months before a lot of the 18-30s are fully vaccinated, and that we haven't yet even started (or decided if/when we will start) vaccinating the under-18s (those being the groups seemingly most responsible for transmission at the moment).

Hence, if our view of the 'probable worst case' (upper bound of current rise-rate estimate) is that we might be up to around 100,000 per day by the end of July (and about 160,000 per day by 10th August) without any relaxations occurring on 19th July, it seems more than a lttle optimistic to be talking about 'only' 100,000 per day "later in the summer" if we do abandon virtually all measures on 19th, as if that were the "worst possible scenario".

In considering these gambles, the UK is clearly putting a vast amount (virtually all) of their faith/hope (which one hopes does not prove to be 'over-optimism' or 'complacency') in the hoped-for future effects of the impressively very high level of vaccination we have already achieved.

Presumably because of that 'faith in vaccination' (and high level of vaccination), the UK has gone out totally on a limb. No other country of which I am aware has ever had a number of cases, and/or the rate of rise of cases, even remotely as high as we are currently experiencing without responding by introducing robust additional measures in an attempt to control the situation - yet, given our 'faith', we are apparently about to remove virtually all of our 'measures'/restrictions in the face of such numbers.

In fact, it looks as if we are getting very close to being the country with the highest virus prevalence (daily numbers of new cases) in the entire world. Our figures are already dramatically higher than those anywhere in Europe, North America and Australasia, and appreciably higher than in most other countries (in most of which cases are fairly stable, or falling).

The below tabulation is of the world's 'top ten' countries in terms of the 7-day average of new cases per day as of 8th July. The UK is currently fourth, but the top two (India and Brazil) are falling quite rapidly (whilst the UK increases quite rapidly), so is is probable that, even without the planned July 19th changes, we will overtake them within a week or three. Only Indonesia and Cambodia are similarly 'high and increasing' to us, and hence in 'a race to the top' with us - so its far from impossible that we will soon hold the prevailing 'world record'. In a subsequent post, I will show graphically what is going on in the 'top five' countries, and how we come with some other European countries.

upload_2021-7-11_14-38-47.png


As an aside, one can't help but wonder what this will mean in terms of international travel, and the airline/tourism industries. It's all very well to be told today that fully vaccinated people returning to the UK from 'amber list' countries will soon not have to self-isolate, but as we approach that 'world record' situation, one has to wonder whether many countries will actually want/accept travellers from the UK (even if 'fully vaccinated'), at least without a period of strict isolation on arrival.

[continued in next post -10,000 character/post limit :) ] ....
 
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[continued from previous post]

So, the above is all pretty negative and 'gloomy', so I really have to offer some suggestions as to what (for what it's worth!) I might personally have considered to be 'more prudent' ...

As above, the greatest cause of uncertainty/concern about the proposed gamble is that it is totally reliant on the assumption that continuing roll-out of vaccination will result, fairly soon, in a marked 'turnaround' of the situation, with the rate of rise of cases reducing and eventually (but 'fairly soon') turning into a fall.

Assuming that happens, since all we currently have to look at is 'the rise', we have not got all that much of a clue (only speculation and guesses) as to when, how slowly/quickly and to what extent that vaccine-related 'improvement' will happen (even without any relaxations on 19th). Given that the age groups which are seemingly most responsible for transmission will not be fully vaccinated for quite some time (probably 2-3 months for the 18-30s, goodness knows when, if ever, for the under-18s), the onset, speed and extent of this 'assumed' (hoped for) reduction of transmissions/cases could easily fall well short of the expectations/ assumptions/hopes implicit in 'the gamble'.

I therefore suppose that I would say that, before we implement any further 'relaxations' (let alone the near-total abolition of all 'control measures'), which will inevitably lead to some further rise in transmission/cases, the prudent approach would have been to at least wait until we see at least some of the 'expected' reduction (and thereby be able to make at least some estimates of how that reduction is likely to proceed/evolve) without any further 'relaxations' - and then try to estimate what the effect of the 'relaxations' might have on top of that.

Conversely, to implement massive 'relaxations', the immediate effect of which will inevitably be a rise in transmission, at a time when (even without those relaxations) transmission is very high and rising rapidly (and with no certainly as to when, how rapidly and to what extent a 'reduction' will come) seems, at least to me, to be "less than prudent"! However, who am I to have a view? :)

As I intimated in my initial comments in the other thread, there is another 'massive gamble'. Even if we are right in 'assuming'/hoping that, because the increasing impact of vaccination, we can allow the prevalence of the virus (reflected by number of new cases) soar into the clouds without that being reflected in a major or 'unacceptable' increase in the number of cases of serious illness (which, when it happens, impacts on hospital admissions and deaths, stressing the NHS), that 'soaring into the clouds' will greatly increase the probability of new variants emerging.

We have no way of knowing when the next 'problematical' variant will appear, nor what its characteristics may be, but it's far from impossible that one will appear against which current vaccines offer little/no protection. That would be disastrous, because it could literally put us back to 'square one', probably resulting in months of strict lockdown (with all the countless consequences of that) whilst we wait for new vaccines to be developed, tested, approved, manufactured and delivered to the majority of the population - and that would very probably take at least a year, probably more.

Variants can only arise during replication of the virus within infected people, so the one (and only) thing we can do to minimise the risk of such a catastrophe is to do everything we can to minimise the number of infected people around - which means that letting the number of them 'soar into the clouds' (since that may not have any serious immediate consequences) is not, to my mind, exactly 'prudent'!

It is no surprise or co-incidence that three of the most worrying variants we have so far seen emerged in South Africa, Brazil and India at times when those countries had extremely large numbers of cases. If, by attaining a 'world record' position (in terms of number of cases) we facilitate the appearance of some potentially 'deadly' (at least 'disastrous') variant, the UK will probably be removed from the Christmas Card Lists of most of the countries of the world. Amongst everything else that has to be considered, we should not forget our 'global responsibilities'.
Sometimes you get to the point where you just have to "rip the plaster off" and get on with life.
That's true, but one has to do so in a responsible and not 'short-sighted' manner which takes into account the many considerations such as you mention.

The stress on healthcare services is one of major issues, since it impacts on non-Covid illnesses (both physical and mental), and particularly on NHS staff, who are becoming exhausted and demoralised. In many senses, the NHS is, already. overwhelmed', not by Covid but by desperate attempts to catch up the massive backlog, and the high current demand for healthcare.

That being the case, unless we adopted the Draconian (and 'unthinkable', even if probably supportable by a Utilitarian argument) policy of interpreting "rip the plaster off" as meaning "we are henceforth not going to offer NHS treatment to people with Covid-19 infection (so that we can treat everyone else)", any appreciable increase in Covid-related hospitalisations could get close to being the last straw which effectively 'totally overwhelmed' the NHS, which could result in serious consequent staffing difficulties, compounding the problem.

Vaccination has certainly considerably weakened the 'link between cases and hospital admissions', such that hospital(and ICU) Covid admissions are currently quite low. However, as you will see from my graphs (if/when I post them), hospital (and ICU) admissions are rising roughly in parallel with cases. That makes sense since, although the proportion of infected people requiring hospital admissions is much lower than it was in the past, there is no reason why, in the short-term, it should not be a fairly constant proportion - so rising pro-rata to the rise in cases. In the longer term, an increasing level of (already very high) vaccination should reduce this proportion further.

At present, hospital admissions are running at 400-500 per day and ICU occupancy at about 400, in both cases around 10% of what both of these figures were (co-incidentally) at the January peak. However, admissions are currently rising at about 6% per day, corresponding to a doubling about every 12 days.

As of today, daily cases are about 50% of the January peak but, as above, hospital admissions (and ICU occupancy) only about 10% of the January peak. However, if they continue to rise 'in parallel' ('pro-rata'), that means that if cases get to more than double the January peak (i.e. more than about 120,000 per day, which is far from impossible) hospital/ICU admissions might be 40% or more of what they were in the January peak - and that would be pretty 'overwhelming' in terms of Covid alone, not to mention the effects on all the other aspects of healthcare.
And yes, I do take this seriously. ...
I hope that virtually all of us take it very seriously. However, whilst we are all aware of the countless 'considerations' which have to be balanced against the risks of Covid itself (considerations in relation to economics, industries, livelihoods, non-Covid heath problems, mental heath problems, education etc. etc. etc.), we also need to try not to be short-sighted.

It can actually be counter-productive to take excessive/premature/'bold' steps (such as currently planned) that will benefit most of those 'considerations' in the short-term if the consequence ends up with our having to suffer a fairly rapid U-turn which could easily result in all those other problems not only returning, but becoming even more protracted than they necessarily needed to be.

... and "there endeth the lesson". I wonder if anyone has got this far? :) Even in terms of those (if any!) who have, I don't expect everyone to agree with what I've written!

I've obviously only scratched the surface of just one of the most topical aspects of this business, but, as I said, I will try to post some graphs fairly soon, which may help to make some of my points more understandable (and also to identify some other 'issues').

We have not got long to wait to hear what Boris has to say, and I just hope that it proves to be the case that he/they will have managed to 'get it right' (even if that requires them to be 'very lucky gamblers'!).

If anyone has any comments or questions, I will attempt to respond!

Kind Regards, John
 
Well that was long! I'd like to break it down somewhat.
The arguments for not relaxing restrictions are predicated on the assumption that legally enforced restrictions are effective in reducing genuine cases and deaths. Are you able to provide evidence that this is so, and if so, to an extent which outweighs the inevitable harms caused by such restrictions?
 
Yes.

The doom-laden language, John, suggests to me that you have already made up your mind.

Do you think that without the restrictions the UK would be many times worse than anywhere else even though it is already (said to be) one of the worst?


The cases are not doubling every ten days. The ONS site states that in the last seven days there were 30% more cases than the previous seven.
On a daily count there were the 32,367 cases on the 10th and 25,637 on the 30th (+27%).

More definition needs to be given in relation to the "cases" and what that means; how many are ill?
Also, what do you think about the efficacy of the PCR tests and the manner in which they are administered and evaluated?

As well as Echoes' post, do you agree that the masks used by the general public and the way in which they are used are all but totally ineffective?



Perhaps we should just ask Professor Ferguson and his colleagues what they think the figures might be and divide by the error factor of his previous fantasies.
 
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A good read John.
The governments around the world really are in a very difficult situation.
Being naturally cautious, I would prefer tight control. But it seems that all we do by lock downs is just postpone the next wave.
Made good sense while the vaccine was developed.
Completely dropping all precautions though is negligent in my opinion. Personal measures to limit your ability to spread the virus, still needs to be enforced.

I don't understand the ineffective mask stance. If you were in a room, and some one was sneezing, would you prefer them to sneeze freely, or contain it in a handkerchief?
I thought things were opening up quite well, life was quite normal really. Don't see the need to rush it.
 
Well that was long! I'd like to break it down somewhat. ... The arguments for not relaxing restrictions are predicated on the assumption that legally enforced restrictions are effective in reducing genuine cases and deaths. Are you able to provide evidence that this is so, and if so, to an extent which outweighs the inevitable harms caused by such restrictions?
Legally-enforced restrictions are obviously not perfect, and compliance with them will probably reduce if they drag on. However, whilst I can't really offer any evidence in relation to the "inevitable harms caused by such restrictions" to anticipate one of the graphs I hope to be posting soon, on the other side of that equation you may regard as 'fairly strong evidence of effectiveness' what was achieved by the January-April lockdown (which I would regard as pretty dramatic) and, conversely, what happened in early June when those restrictions started to be appreciably 'relaxed'. Even the brief November lockdown had an appreciable effect:

upload_2021-7-11_17-12-59.png


Kind Regards, John
 

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I actually can't accept that as evidence of the effectiveness of lockdown. I think you have fallen for the 'post hoc ergo propter hoc' fallacy.
What we see are classic Gompertz curves, characteristic of this type of disease observed in all temperate countries regardless of the severity of lockdown.

We see the same curve characteristics for the first wave and the first lockdown in spring 2020. We see it in countries with strict lockdown, and we see it without lockdown.

There is ample literature to support the null hypothesis.
 
Yes. The doom-laden language, John, suggests to me that you have already made up your mind.
I have not, and could not, 'make up my mind' about what is going to happen. However, I (and many others) have definite views about what might happen - so, as I said, it all comes down to what attitude 'we' (the government) take to the 'gambling'.
Do you think that without the restrictions the UK would be many times worse than anywhere else even though it is already (said to be) one of the worst?
I suppose that depends upon what you mean by 'worst'. In terms of numbers of cases, the UK is already approaching have the most in the world, and I don't think anyone doubts that the upcoming relaxations are going to cause those figures to rise appreciably, atv least in the short-medium term. As I've said, that means that it's pretty likley that the next 'worrying' variant will arise in the UK, and it will be pot luck as to whether it is 'of nuisance value' or 'catastrophic'.
The cases are not doubling every ten days. The ONS site states that in the last seven days there were 30% more cases than the previous seven. On a daily count there were the 32,367 cases on the 10th and 25,637 on the 30th (+27%).
There is a fair bit of fluctuation, and I'll be presenting some actual chapter and verse as soon as I can. I'll discuss the actually numbers, and the pattern of increase, later, but there is certainly as yet no appreciable sign of any reduction in the rate of rise:

upload_2021-7-11_18-0-47.png


More definition needs to be given in relation to the "cases" and what that means; how many are ill? Also, what do you think about the efficacy of the PCR tests and the manner in which they are administered and evaluated?
Those are all important issues, but fairly static ones, so they do not have any major impact on observed changes over time -0 in the UK or anywhere else.
As well as Echoes' post, do you agree that the masks used by the general public and the way in which they are used are all but totally ineffective?
I have never believed that they offer appreciable protection to the wearer. However, there seems to be reasonable evidence that they do provide a degree of protection (certainly 'better than nothing') to 'others' if the wearewr is infected.

Kind Regards, John
 
A good read John. The governments around the world really are in a very difficult situation.
Definitely.
Being naturally cautious, I would prefer tight control. But it seems that all we do by lock downs is just postpone the next wave.
We are in an almost unique position in the UK, with such a high level of vaccination. If we waited just a few more weeks for our 'freedom' (and, ideally, vaccinated the under-18s, which probably won't happen),m the 'next wave' might no happen to any large extent - at least, until a variant comes along against which current vaccines offer little/no protection (a risk increased by our allowing case numbers to soar).
... Completely dropping all precautions though is negligent in my opinion. Personal measures to limit your ability to spread the virus, still needs to be enforced. I don't understand the ineffective mask stance. If you were in a room, and some one was sneezing, would you prefer them to sneeze freely, or contain it in a handkerchief?
I personally agree. As I said in the other thread, I suspected that mask-wearing indoors was one aspect of the 19th July relaxations which might not happen - and its sounds today as if the government are veering in that direction. As I recently wrote, I've never believed that face coverings offer much protection to the wearer, but is seems that they are. at the least, 'better than nothing' in terms of protecting 'others'.
I thought things were opening up quite well, life was quite normal really. Don't see the need to rush it.
Again, and as is probably apparent from what I've been saying, I personally agree - but who am I to have an opinion?!

Kind Regards, John
 
Varients happen all the time. It is very unlikely that a varient with a disastrous vaccine escape will retain its infectiousness. This is why the vaccine was targeted where it was.

Cases will rise with such an infectious virus hitting what was essentially an unvaccinated group of the population. What's key is if this quickly translates to secondary infections or hospitalisations.

Depending on this, releasing restrictions over summer can have benefits - due to bringing the hospitalisations timing into a sweetspot, rather than delaying them to a worse point in time - with the current state of play, somewhat surprisingly a lockdown will not prevent these hospitalisations.
 
The 'exponential' word is cropping up far more than the actual data permits.
The rising part of these curves is never exponential. The falling part is.
 
I actually can't accept that as evidence of the effectiveness of lockdown. I think you have fallen for the 'post hoc ergo propter hoc' fallacy. ... What we see are classic Gompertz curves, characteristic of this type of disease observed in all temperate countries regardless of the severity of lockdown. .... We see the same curve characteristics for the first wave and the first lockdown in spring 2020. We see it in countries with strict lockdown, and we see it without lockdown.
I can't really agree with that which, if I understand you correctly, is largely based on the assumption of 'seasonality', for which there is relatively little evidence with Covid-19. I very much doubt that any country has seen a rapid decline in cases without implementing some sort of 'control measures', the natural history of such epidemics generally being that the number of cases will not start falling until so many people have been infected that the susceptibility of the population decreases (i.e. as one approaches 'herd immunity').

You are surely not suggesting that the rapid falls in cases which followed soon after our implementation of lockdowns (in March, November and early January) were 'co-coincidences', or even the result of seasonal factors, are you?

Kind Regards, John
 
However, there seems to be reasonable evidence that they do provide a degree of protection (certainly 'better than nothing') to 'others' if the wearewr is infected

Can you provide any citations for this, beyond the mannequin / droplet studies? (Flawed by the way since it is aerosols which count).
 
Varients happen all the time.
They will, but obviously more frequently in populations/countries with a high prevalence of infection. As I said, variants can only arise during replication in infected people, so, the more infected people there are .... !!
It is very unlikely that a varient with a disastrous vaccine escape will retain its infectiousness. This is why the vaccine was targeted where it was.
I'm no virologist, so I can't comment on that but, on the basis of what I do know, I don't see. mechanistically, why that necessarily has to be be the case
Cases will rise with such an infectious virus hitting what was essentially an unvaccinated group of the population. What's key is if this quickly translates to secondary infections or hospitalisations.
That would be true if the variant itself was relatively 'benign' (as well as having 'vaccine escape') but, as above, I don't know how confident we can be that such will necessarily be the case. Them main 'variants of concern' we have so far seen all seem to exhibit some degree of 'vaccine escape', but have tended to be more, rather than less, infectious.
Depending on this, releasing restrictions over summer can have benefits - due to bringing the hospitalisations timing into a sweetspot, rather than delaying them to a worse point in time - with the current state of play, somewhat surprisingly a lockdown will not prevent these hospitalisations.
That is, of course, one of the main arguments being presented for 'now' - I just hope that it proves to be a prudent approach - although, as you will realise, I have my uncertainties about that.

Kind Regards, John
 

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